Woodleigh Rest Home Limited

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.
At our last assessment we rated this key question inadequate. At this assessment, the rating has changed to good. This meant people were safe and protected from avoidable harm.
 

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Systems were in place to record and review accidents, incidents and falls. Records we reviewed contained sufficient detail, and the provider had undertaken analysis to identify trends and patterns. This demonstrated a proactive approach to learning from incidents and reducing future risk.
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Assessments were completed prior to people moving into the service, including those undertaken by trusted assessors or social workers, and information was shared between professionals to support continuity of care. One relative told us, “The staff asked lots of questions about [person], their likes/dislikes, food preferences, hobbies and such.”
People were also supported to visit the service before admission, which helped them to settle more easily. A relative told us, “We never needed an appointment and each time we visited we were made to feel very welcome,” reflecting an open and person-centred approach to admissions.
 

The provider did not always demonstrate consistent oversight in safeguarding, particularly in monitoring restrictions, although systems were in place and people were generally protected from harm.
People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In [care homes/hospitals], this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that oversight of Deprivation of Liberty Safeguards (DoLS) required improvement. We found the DoLS tracker was not consistently updated, with some applications showing no recorded outcome for extended periods. This meant the provider could not always demonstrate clear oversight of restrictions placed on people.
However, safeguarding systems were established, with well-organised records and monthly analysis of safeguarding concerns completed. Mental Capacity Act (MCA) assessments and best interest decisions were also in place where required, supporting the safe management of people’s care.
 

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things which mattered to them.

Risk assessments were in place and reflected people’s needs. People were supported to take positive risks. For example, people who smoked were enabled to continue doing so with appropriate safety measures in place, demonstrating a balanced approach between safety and independence.
 

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.
Parts of the environment were worn and required updating. Some bedrooms appeared tired, and although the provider had a refurbishment plan in place, improvements were not yet fully completed at the time of inspection. Toilet refurbishment had not been completed, which limited bathing facilities to 1 working bathroom. In addition, the only toilet on the first floor had been taken out of use without the provider’s awareness, and a downstairs toilet in use required repair.
However, once these issues were identified, immediate action was taken to address them, including arranging repairs.
The provider had systems in place to maintain the safety of the environment, including servicing and maintenance records. Where servicing had not been arranged prior to the assessment, prompt action was taken to address this, demonstrating a responsive approach to maintaining a safe environment.
 

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff told us staffing levels could be improved, particularly to support the layout of the home and respond more effectively across areas during busy periods. However, they also said staff worked well together to maintain people’s safety, and knowledge and understanding had improved since the last assessment, supporting more consistent and informed care.

We observed staffing levels appeared sufficient to meet people’s needs at the time of the assessment, and there was a consistent and visible staff presence in communal areas to support people safely.

Safe recruitment processes had been followed. The provider maintained an up-to-date training matrix, which demonstrated staff had completed mandatory training and were supported to refresh their knowledge when required. Records also showed staff were receiving regular supervision, which provided opportunities to review practice, discuss performance and identify any further learning needs, helping to ensure staff remained competent and confident in their roles.
 

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.
Infection prevention and control (IPC) practice was not consistently in line with guidance. For example, staff were not always bare below the elbows, food was not consistently covered when being transported from the kitchen, and the cat which belonged to and lived at the service was observed on tables during mealtimes. There was only 1 domestic staff member on duty each day for between 3 and 5 hours. Despite staff making efforts to maintain standards, some areas of the home were not consistently cleaned. Night staff were also responsible for cleaning communal areas; however, they needed to prioritise the care and safety of people. This indicated IPC practices were not fully embedded.
However, systems were in place to support cleanliness, such as cleaning schedules and supplies, and staff were aware of their responsibilities in this area. We observed improvements between the first and second day of the assessment, demonstrating a willingness to respond and take action to improve standards.
 

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were managed safely, and people received their medicines as prescribed. Medicines were stored securely, with appropriate temperature monitoring in place, including for refrigerated items, and stock levels were regularly checked and found to be accurate. There were no missed doses identified on medication administration records. Systems were in place to support the safe administration of medicines, including body maps for topical creams, rotation charts for patches and risk assessments for specific medicines such as flammable creams. As required (PRN) protocols were in place and records showed these were administered in line with prescribers’ instructions. Although most practices were safe, guidance for variable dose PRN medicines was not always sufficiently detailed, which could lead to inconsistencies in administration. This was recognised by the management team, and action has been taken to address this.